Sobell & Sobell 2003 MOTIVATIONAL INTERVIEWING OVERVIEW & TIPS GOAL To get people to resolve their ambivalence (i.e., conflict) about changing their behavior, while not evoking resistance (e.g., get confrontational, blame, label) WHAT IS MOTIVATIONAL INTERVIEWING? A directive, client-centered counseling style. It elicits behavior change by helping clients explore and resolve ambivalence. It helps resolve ambivalence by increasing discrepancy between client s current behaviors and desired goals while minimizing resistance. During MI empathic listening is essential to minimizing resistance. MOTIVATIONAL TECHNIQUES CAN HELP PEOPLE TO CHANGE BY Recognizing their high risk behavior (e.g., personalized feedback; pie chart where do I fit in?) Evaluating how much of a problem their behavior is for them currently in relation to other issues in their life (e.g., Decisional Balance exercise, personalized goal evaluation) Looking at ways to begin the process of changing (e.g., identify client s strengths; develop action plans) EMPATHY Empathy is one of the most important elements of motivational interviewing; high levels of empathy during treatment have been shown to be associated with positive treatment outcomes across different types of psychotherapy. Expressing Empathy: What is it? Listening in a supportive, reflective manner; demonstrating you understand their concerns and feelings. A specifiable and learnable skill for understanding another s meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning. The key to expressing empathy is reflective listening. An Empathic Style Communicates respect for and acceptance of clients and their feelings Encourages a nonjudgmental, collaborative relationship Establishes a safe and open environment for the client that is conducive to examining issues and eliciting personal reasons and methods for change Allows clinician to be supportive and a knowledgeable consultant Compliments rather than denigrates Listens rather than tells Gently persuades, with the understanding that change is up to the client Provides support throughout the process of recovery Understands each individual client s unique perspective, feelings, and values 1
FIVE BASIC MOTIVATIONAL INTERVIEWING SKILLS 1. Ask Open-Ended Questions (OE) Therapist (T): Tell me a bit about your work (OE). Client (CL): I m a lawyer with a large company. There is a lot of pressure to produce and bring in new clients. 2. Reflective Listening (RL) Paraphrase clients comments. Make reflections as statements where the inflexion goes down at the end. Primary way to respond to clients. T: It sounds like your work is quite stressful. (RL) CL: Yes, but it is quite challenging, pays well and I like going to court to try cases. T: So even though your work is stressful, you find it rewarding (RL) CL: Well most of the time, but lately I wonder where it is all going. T: What other concerns do you have about your work? (OE) CL: That s a good question. Actually there have been cut backs lately--downsizing they call it. I just can t relax anymore. T: What kinds of things have you done in the past to relax? (OE) CL: Biking, but lately I m too tired. T: What other kinds of things help you relax? (OE) CL: Going to a good restaurant at the end of the week with my wife and having friends over and preparing a gourmet meal for them. But again, lately I haven t done those things much either. Different Types of Reflective Listening SIMPLE REFLECTION: reflects exactly what is heard CL: I don't want to quit. T: You don't think quitting will work for you. DOUBLE-SIDED REFLECTION: reflection presents both sides of what the client is saying; extremely useful with pointing out ambivalence CL: There is no question that my children come first. However, after I put them to bed I do not really see any problem in continuing to smoke weed every night. I am very careful where I buy it so I don t get caught in a sting. T: So, on the one hand you seem to be very clear that your children are very important to you and they come first. However, you also appear to be saying that you really don t see anything wrong with your regular use of weed and even appear to discount any risk you might be taking. AMPLIFIED REFLECTION: amplifies or heightens the resistance that is heard CL: I could not quit. What would my friends think? T: It sounds like there would be a lot of pressure from your friends if you tried to stop. 3. Elicit Self-Motivational Statements Get clients to give voice to how they are changing; point out any changes you have observed with the client and ask them how they did this. T: It sounds like you have made real progress. How do you feel about that? 4. Affirm (support, encourage, recognize client s difficulties) T: It sounds like you are still struggling with making these changes, but you have made some changes. How do you think you might reduce your drinking even further? 5. Summary Statements (SS) pull together the comments made; transition to next topic T: You mentioned a number of things about your current lifestyle, such as cutbacks at work and the stress you feel. You spoke of having little energy for doing some of the things you used to like to do and did to relax. What do you think might help you get back doing some of the things you once enjoyed? 2
Reframing Places a different meaning on what the person says so that the person doesn't seem so resistant CL: My parents have really gone crazy over my being caught at school smoking cigarettes, and want me to seek counseling. Sure I know the school was going to suspend me but my parents intervened and said I could come here for counseling. T: It sounds like you feel your parents were being over reactive, but their actions also seem to have been the one thing that kept the school from suspending you. What do you think about that? Developing Discrepancy Create a gap between where the person has been or currently is and where they want to be; goal is to resolve discrepancy by changing behavior STRATEGIES Tell me some of the good things and less good things about your behavior/concern. What will your life be like (# years from) if you don t make changes and continue to use? Explore how a client s life would be different if he/she did not have the problem or were not engaging in the behavior. What was your life like before you started having problems with (the behavior)? Describe a typical day. VERBALIZING AMBIVALENCE In what ways has your behavior been a problem? What have other people said? If it is not viewed as a problem now, how might your use eventually become a problem? In what ways has it been inconvenient for you? RECOGNIZING AMBIVALENCE (decisional balance) What are the good things about your behavior? What are the less good things about your behavior? If you keep heading down the road that you re on what can you imagine happening? What would be the best outcome you could see for yourself? LOOKING FORWARD If you keep going the way you are going where will you be five years from now? Where would you like to be five years from now? What goals/things do you want for yourself? Have them list these on cards, and then put the cards in order of priorities. Which is most important? Which is least important? Then ask them where their behavior fits in. Point to the highest priorities and ask them How many of your priorities would you be willing to give up for your current behavior? Elaboration When clients offer something bad about their behavior, ask them to talk more about it. Ask for an example, and then ask for another example. Colombo Technique Used when clients are presenting conflicting information or behaviors T: On the one hand you say you are terrified of going to prison, but you continue to (engage in the behavior). I'm confused. Help me understand this." Therapeutic Paradox Side with the side of the ambivalence; presents the client with a challenge; do not have sarcasm in your voice for this needs to be stated genuinely Example #1 (T): "Maybe what I'm asking is just too difficult for you. Maybe you are not ready to change. Example #2 (T): You have been continuing to drink heavily and yet you say that you want to get you children back. Maybe you are not ready to change. 3
Emphasizing Personal Choice and Control If you tell someone what to do this is confrontational and fosters resistance. Allowing personal choice and control over their problems can help minimize resistance READINESS TO CHANGE RULER People come into treatment with different levels of motivation (or readiness) to change At the assessment/first session, ask On the following 5-point scale from 1 to 5 where 1 is Not Ready and 5 is Ready where are you now in terms of changing your behavior? People move forward and back along this readiness to change scale A therapist needs to operate at the same level of change where the client is in order to minimize resistance and gain cooperation On the following scale (show client) from 1 to 5, what number best reflects how ready you are at the present time to change your (the behavior)? Circle one of the following. Not Ready to Change Thinking of Change Undecided/ Uncertain Somewhat Ready Very Ready to Change 1 2 3 4 5 SCALING EXAMPLES Scaling Multiple Problems I realize that it may be difficult to put numbers on each of the problems we discussed. Say, 5 is the most urgent and 1 the least. How do you think you would rate your drinking problem? What number would you give to each of your other problems marriage, health. Coerced Clients Ask their view of referring person s expectations (be empathic) T: I guess you have better things to do on a day like this than to sit and talk to a strange therapist. So, what do you think your guidance counselor believes has to happen so she feels you won t have to come here anymore? T: What do you suppose your guidance counselor will have to see happen for her to believe that you don t have to come back to see me? T: What will convince your guidance counselor that you are a good kid? T: Sounds like it has been a tough situation at home. NOTE: Conversation does not focus on substance use, but on concerns of the client. Coerced Clients Questions to negotiate goals with coerced clients: Whose idea was it that you come here? Who suggested you come here? What makes (Name Referring Person: NRP) think that you need to come here? What will convince (NRP) that you don t need to come here? What does (NRP) think is the reason that you have (name of the behavior)? What does (NRP) say you need to do differently? Scaling Self-Esteem T: Let s assume that when you first started therapy the problem that brought you here was a 1 and where you want to be after you finish treatment is a 10; where would you say you are today, between 1 and 10? CL: I would put myself at 4. 4
T: What would you say you have to do to move up from 4 to 5? T: Let s imagine that two months from now you have moved to a 7. What do you suppose your spouse/son will notice is different about you that will tell them you are at 7? Scaling Question: Example #1 T: Let s say 10 means how you want your life to be when you solved the problem that brought you here, and 1 means how bad things were when you picked up the phone to schedule an appointment; how would you rate your problem today? CL: I would say a (#). T: Is that unusual for you? T: So, what would it take to go from (#) to (#)? Scaling Question: Example #2 Therapist: Suppose 10 means you will do anything to stop drinking, change your life around, and do what is good for you and 1 means all you are willing to do is to sit and do nothing; where would you say you are today? Client: I am at a 5 today. Therapist: So, you ve come a long way. What do you have to do to move up from 5 to 6? MOTIVATIONAL INTERVIEWING REFERENCES Martino, S., Carroll, K. M., O'Malley, S. S., & Rounsaville, B. J. (2000). Motivational interviewing with psychiatrically ill substance abusing patients. American Journal on Addictions, 9(1), 88-91. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change (2nd edition). New York: Guilford. Resnicow, K., Dilorio, C., Soet, J. E., Borrelli, B., Hecht, J., & Ernst, D. (2002). Motivational interviewing in health promotion: It sounds like something is changing. Health Psychology, 21(5), 444-451. Rollnick, S., & Allison, J. (2001). Motivational interviewing. In N. Heather, T. J. Peters & T. Stockwell (Eds.), International handbook of alcohol dependence and problems (pp. 593-603). New York: John Wiley. Sobell, L. C., & Sobell, M. B. (2003). Using motivational interviewing techniques to talk with clients about their alcohol use. Cognitive and Behavioral Practice, 10, 214-221. Substance Abuse and Mental Health Administration. (1999). Enhancing motivation for change in substance abuse treatment (Treatment Improvement Protocol Series). Rockville, MD: U.S. Department of Health and Human Services. [NOTE: Can be obtained free of charge from the National Clearinghouse for Alcohol and Drug Dependence by calling 1-800-729-6686 and asking for DHHS Pub # SMA 99-3354 or http://store.health.org/catalog/sc_itemlist.aspx] 5